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LOCATION TPID 100sy74 It .RS' , PLEASE REMIT TO: <br /> 4001 N. Vasco Road ®y�arca ;a;n, ea:aetx: P.O.Box 83328 <br /> Livermore,CA 94551 �_' ;Z. '>; t»'_z Portland,OR 97203 <br /> (925)447-0972 WASTE RECOVERY WEST. INC. <br /> Fax(925)456-7794 1-877-OLD-TYRE <br /> P"Hauler ❑Generator ❑End Use Facility <br /> ! l- �ickup <br /> Invoice Date —/-/O' C'> Load Dated*) —/i� �� Rhone# ❑Delivery <br /> Customer Name_�/�� �Y(Jl'�' �C y�� �r1)2 C Acct# <br /> Sit, <br /> Street Address 2.5,�?e5 /2t City �� State <br /> DRIVER - I certify that under penalty.of perjury under the laws of the State of California that the information provided is true and correct.In addition,I,am <br /> aware that falsification of this information may result in suspension,revocation,or denial of renewal of the Waste Tire.Hauler Registration pursuant to <br /> Public Resources Code section 42960 and may result in civil penalties up to$25,000 per day,per violation or administrative penalties up.to$5,000 per <br /> X violation per day as described in Public Resources Code section 42962. Hauler Exemption EI Government ❑LEA <br /> - E]Agriculture OCommonICarrier <br /> TRUCK t HA R TRLR T TRLRS,� VE HELPER; MANIF.EST N ' A /CHARGE <br /> LI PLATE 9 DEC L A LIC STATE IMPORT❑ OCATION CUSTOMER TBIDE: TRIP LOG . <br /> O t7 � EXPORT <br /> LOAD AMOUNT- <br /> QUANTITY Description LOAD TYPE <br /> u_T Y_,p Rate Amount <br /> I <br /> I <br /> Customer Signature /jam i Total Amount$ <br /> s pt <br /> I certify that'under penalty of pe'ury under the laws of the State of i ornia that the' rmation provided above is true and <br /> correct.In additioq,I am aware that falsification of this information m result in civil pen ties up to$25,000 per day,per violation i <br /> or administrative penaldes up to$5,000 per violation per day as descri in lic Resou r es Code section 42962. INVOICE C 11644 <br /> ^�U <br /> Uv � <br /> v <br />